Comment on: Dramatic response to intravitreal bevacizumab in hypertensive retinopathy.

Sir,

We read with interest the case report[1] on the resolution of bilateral subfoveal fluid and disc edema due to hypertensive retinopathy (HTNR) after unilateral intravitreal bevacizumab. We want to discuss few points.

As one eye did not receive the intravitreal injection, one could consider that eye as the control eye as opposed to the other interventional eye with intravitreal injection. Resolution of the control eye's subfoveal fluid after 1 month of the intervention may denote a positive effect of the control of blood pressure (BP) or systemic disease and may not solely be related to the contralateral effect of the injection as the authors have proposed. It would be interesting to know if the patient underwent any interventions to control BP including hemodialysis.

Typically mean arterial BP (MABP) is calculated as diastolic BP + (systolic BP − diastolic BP)/3. Thus, the calculated MABP of 210/140 mm Hg would be 140 + (210 − 140)/3 = 163.3 mm Hg and not 136 mm Hg. Was MABP measured invasively by an arterial line?

As the primary cause of HTNR is hypertension, the adequate control of hypertension is the most important intervention. Without the adequate control of BP, any intervention including intravitreal anti-vascular endothelial growth factor (VEGF) agents may not be considered. Though bevacizumab has been considered as a “wonder drug,” it carries a rare but devastating risk of blindness due to endophthalmitis.[2] However, in the clinical setting even after control of hypertension, the subfoveal fluid may not resolve and the patient may want earlier visual rehabilitation. Salman[3] used intravitreal bevacizumab in 12 cases of persistent HTNR despite control of hypertension for 1 month and noted stabilization and improvement of vision in all cases. This paper[1] also adds to the evidence[45] that anti-VEGF agents may be helpful in HTNR. The exact role of anti-VEGF agents in HTNR needs further exploration, but these agents may add to the armamentarium to treat the cases of HTNR with subfoveal fluid which do not resolve despite good systemic control.

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